Genetic Predisposition to Gallbladder Stones

• ABSTRACT
• GENETIC AND GENOMIC ASPECTS OF GALLSTONE FORMATION
• Evidence for a Genetic Predisposition to Gallstones
• Pathophysiology of Gallstone Formation and Genes Putatively Involved
• Oligogenic Predisposition to Cholelithiasis
• “Common” Polygenic Predisposition to Gallstones
• FUTURE STRATEGIES FOR PREVENTION AND TREATMENT OF GALLBLADDER STONES BASED ON THE GENETIC PREDISPOSITION TO GALLBLADDER STONES
• i ACKNOWLEDGMENTS
• ABBREVIATIONS
• REFERENCES

ABSTRACT

Geographic and ethnic differences in gallstone prevalence rates and familial clustering of cholelithiasis imply that genetic factors influence the risk of gallstone formation. Recently, twin, family, and linkage studies confirmed a genetic predisposition to the development of symptomatic gallstones. In rare instances, mutations in single genes confer a substantial risk for the formation of gallstones. However, in the majority of cases gallstones might develop as a result of lithogenic polymorphisms in several genes and their interactions with multiple environmental factors, rendering gallstones generally a complex genetic disorder. Some of the rare monogenic forms of cholelithiasis were unraveled but the lithogenic genes that increase the susceptibility to cholelithiasis in the majority of gallstone carriers remain elusive. Identification of these lithogenic genes will provide novel means of risk assessment, strategies for prevention, and targets for nonsurgical management of cholelithiasis, which currently is one of the most expensive digestive disorders.

Gallstones are solid calculi that precipitate in bile and in most instances form and remain in the gallbladder. Gallstones may precipitate if the amounts of cholesterol or bilirubin in the gallbladder exceed their solubility products. As a result of supersaturated bile, combined with other coexisting factors, either cholesterol gallstones develop that are principally composed of cholesterol monohydrate crystals[1] or calcium bilirubinate polymerizes to form “black pigment” stones.[2] A third class of gallstones known as “brown pigment” stones are composed of hydrolyzed products of biliary phospholipids and pigments that precipitate as calcium salts of sparingly soluble lipids and calcium bilirubinate and are typically a result of infection with hydrolyzing bacteria.[3] [4] These stones, in most instances, form in the bile ducts and consequently are not a subject of this review.

The majority of gallstones are asymptomatic; however, ~25% of gallstone carriers develop symptoms or severe complications of cholelithiasis.[5] Because up to 50% of symptomatic gallstone carriers experience a second episode of biliary pain within 1 year and the risk of complications such as cholecystitis, cholangitis, and biliary pancreatitis increases by a factor of 10 after the initial symptoms occurred, treatment of symptomatic gallstones is warranted.[1] At present, surgery is the common treatment of the underlying cholecystolithiasis. Each year ~700,000 cholecystectomies are performed in the United States, rendering gallstones the second most expensive digestive disorder, surpassed only by gastroesophageal reflux disease and generating medical costs of $6.5 billion annually.[6] In this review, we summarize the evidence for a genetic background of gallstones, list genes putatively involved, and describe future strategies to unravel the genetic mechanisms that predispose to gallstone formation. We envisage that identification of the principal genetic factors will facilitate the definition of the complete pathophysiology of gallstone formation and provide novel means of risk assessment, prevention, and nonsurgical management of cholelithiasis.

GENETIC AND GENOMIC ASPECTS OF GALLSTONE FORMATION

Evidence for a Genetic Predisposition to Gallstones

Surveys based on ultrasound examination revealed considerable variation in gallstone prevalence rates in different geographical areas.[7] In the United States and in Europe, gallstones are extraordinarily widespread with prevalence rates of 8% to 22% as assessed by cross-sectional ultrasound studies.[8] In contrast, gallstones are substantially less frequent in Asia and Africa but common among whites in Southern Africa.[9] In addition to geographic variation, differences in gallstone prevalence rates were noticed among diverse ethnicities.[8] The astonishingly high prevalence of gallstones among American Indian tribes has been recognized for decades.[10] A systematic survey in descendants of American Indian tribes in the United States found gallstone prevalence rates as high as 66% in women and 33% in men and confirmed a positive correlation of American Indian heritage with gallstone formation.[11] Ethnic differences in gallstone prevalence were indicated further by a population-based survey in the United States that identified higher age-adjusted gallstone prevalence rates in Mexican-American women compared with non-Hispanic white and non-Hispanic black women.[12] This observation is also supported by the results of a study in Mexicans that detected an association of a human leukocyte antigen (HLA) allele characteristic for American Indian populations (HLA-B39) and gallstone prevalence.[13] Finally, the hypothesis that American Indian ancestry leads to an increased risk to develop gallstone was substantiated in a study that demonstrated an association of gallstone prevalence rates and heritage of American Indian mitochondrial DNA in Mapuche Indians from Chile, Hispanics, and Maoris of the Easter Islands.[14] Taken together, these data support the notion that American Indian heritage confers an increased risk for gallstone formation in populations across North America, Latin America, and South America.

Notably, gallstones in American Indians became endemic only with severe environmental changes, that is, abandoning the traditional lifestyle and adaptation of a western-type diet.[15] This observation led to the application of the “thrifty genes” hypothesis to gallstone formation. The hypothesis was previously formulated for obesity and diabetes mellitus[16] and is based on the origin of Paleo-Indians in Central Asia and their migration to North America during the last great ice age.[15] It is assumed that in times when food was limited, genetic variation that increased the ability to store fat was beneficial. However, the genetic background that was advantageous in times of poverty might be detrimental following environmental changes that led to an abundance of food and originated in susceptibility to weight gain, diabetes, and gallstone formation.[15] Indeed, epidemiological studies confirmed an association of obesity[17] and impaired insulin resistance[18] with gallstone formation supporting the thrifty genes hypothesis. Furthermore, the observations in American Indians illustrate that a genetic predisposition alone is not sufficient but that gallstones develop in genetically predisposed individuals in response to environmental factors. Interestingly, increases in gallstone prevalence rates similar to those observed in American Indians were documented in postwar European countries in the 20th century and more recently in cities in Asia that, likewise in part, can be attributed to a prevailing genetic susceptibility to gallstone formation unmasked by changes in lifestyle and diet.[9] In Europe, gallstone prevalence rates display an apparent north-south divide with highest prevalence rates in Northern and Central Europe but intermediate prevalence rates in southern parts of the continent.[9] However, the hypothesis that a mechanism similar to the spread of American Indian thrifty genes across the Americas with a distribution of “thrifty Viking” genes accounts for regional differences of cholelithiasis across Europe remains speculative.[15] [19]

In addition to geographic variation and ethnic differences in gallstone prevalence rates, clustering of gallstones in families was noticed with a two- to fivefold increased risk for cholelithiasis among first-degree relatives of gallstone carriers in studies from Europe.[17] [20] Subsequently, a study in the United States confirmed a family history of previous cholecystectomy as a principal risk factor for the development of symptomatic gallstones.[21] Family studies per se cannot differentiate between a genetic predisposition and shared environmental factors among relatives in the development of a trait. To this end, twin studies can be revealing. Dizygotic twins usually share the same environment but only 50% of their genes, whereas monozygotic twins are genetically identical. Therefore, concordance rates in monozygotic twins in excess of those in dizygotic twins are considered an ideal method to assess for and quantify genetic contributions to a trait. Generally, the effects of genetic factors are more pronounced in younger compared with older individuals and accordingly, in a recent twin study from Sweden, concordance rates for symptomatic gallstones in younger twin pairs were higher than in older twin pairs.[22] Twin pairs between 44 and 63 years of age were found to have concordance rates of 24% versus 14% in females and 19% versus 11% in males for monozygotic and dizygotic twins, respectively.[22] Based on the data from this remarkably large study, which included 43,141 twin pairs, genetic factors were calculated to account for 25% of the variation for the development of symptomatic gallstones.[22] These data confirm the results of a previous smaller family study that revealed a heritability of as much as 44% for symptomatic gallstone disease in Mexican-Americans.[23] Although these studies were limited to the analyses of the heritability of symptomatic gallstones, the results are in agreement with a genetic predisposition to the formation of gallstones. Combining these facts with the geographical and ethnic differences of gallstone prevalence rates, it emerges that a complex genetic predisposition involving lithogenic polymorphisms in several genes (termed LITH genes) and their interactions with multiple environmental factors determines the risk for developing gallstones.

Pathophysiology of Gallstone Formation and Genes Putatively Involved

Bile is an aqueous solution of cholesterol, phospholipids, bile salts, and the bile pigment bilirubin.[8] Biliary lipids and bilirubin are secreted into bile by energy-dependent transport processes across the canalicular membranes of hepatocytes that are facilitated by adenosine triphosphate (ATP)-dependent transport proteins.[24] In contrast, the secretion of water into bile and consequently bile flow is a passive process driven by the osmotic forces of solutes in bile, the most important being bile salts.[25] The composition of hepatic bile is further modified by different functions of cholangiocytes, including chloride transport into bile by the cystic fibrosis transmembrane conductance regulator (CFTR)[26] and water channels (i.e., aquaporins), which are expressed on cholangiocytes.

The molecular mechanisms resulting in the formation of cholesterol gallstones differ from the conditions leading to the development of black pigment stones that principally comprise polymerized salts of calcium bilirubinate.[2] Unconjugated bilirubin is derived from degradation of heme proteins (such as hemoglobin and myoglobin) and because of its insolubility in blood is delivered to the liver bound to albumin. The transport processes involved in hepatocellular uptake of bilirubin are still poorly defined.[27] In hepatocytes, conjugation of bilirubin is catalyzed by the enzyme UDP glucuronosyltransferase, encoded by UGT1A1, to form bilirubin glucuronides.[28] Bilirubin conjugates are secreted into bile via the multiple resistance-related protein 2 (MRP2) that is localized in the canalicular domain of the hepatocellular plasma membrane and encoded by the ATP-binding cassette (ABC) transporter gene ABCC2.[29] Most bilirubin conjugates present in bile are diglucuronides, whereas only small amounts of monoglucuronides are present under physiological conditions.[2] Unconjugated bilirubin in bile derives from hydrolysis by endogenous β-glucoronidases and is present as monoacidic bilirubinate at the normal biliary pH. Unconjugated bilirubin and calcium are kept in micellar solutions with bile salts or solubilized in phospholipid vesicles. When the ion product of unconjugated bilirubin and calcium exceeds its solubility product, calcium bilirubinate [Ca(HUCB)₂] precipitates and polymerizes in biliary sludge.[2] Principally, black pigment stones form if (1) the amount of unconjugated bilirubin delivered to the liver increases, (2) the capacity of the liver to conjugate bilirubin is reduced, and (3) enhanced β-glucuronidase activity in bile results in augmented hydrolysis of conjugated bilirubin and larger quantities of unconjugated bilirubin overwhelming the capacities of micelles and vesicles for solubilization.

Bile is the major conduit to eliminate excess cholesterol from the body, either by biliary secretion of unesterified cholesterol or by biliary secretion of bile salts, the principal catabolic product of cholesterol. In humans, most cholesterol assigned for biliary secretion is derived from two sources: (1) high-density lipoproteins (HDLs) that carry cholesterol from peripheral organs to the liver[30] or (2) cholesterol of dietary origin transported to the liver in chylomicron remnants, which are rich in cholesteryl esters.[31] In contrast, contributions from cholesterol delivered to the liver from low-density lipoprotein (LDL) cholesterol and cholesterol from hepatic de novo synthesis are minor.[32] Accordingly, treatment with inhibitors of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase, the rate-limiting enzyme of cholesterol synthesis, does not result in protection from gallstone formation.[33]

HDL, as the major cholesterol carrier of the reverse cholesterol transport between periphery and liver, undergoes several modifications including the transfer of cholesteryl esters between lipoproteins by the cholesteryl ester transfer protein (CETP). Even though studies in mice (in which CETP is absent) indicate that reverse cholesterol flux is not determined by the absolute concentration of plasma HDL,[34] hepatic uptake of esterified and free cholesterol following binding of HDL particles to the scavenger receptor B-1 (SCARB1) is an important source of cholesterol for biliary secretion.[35] This concept is supported by epidemiological studies that suggest an association of lower plasma HDL cholesterol levels and gallstone prevalence rates.[9] Absorption of cholesterol derived from dietary sources and bile in the small intestine involves the recently discovered Niemann-Pick C1-like protein 1 (NPC1L1). Subsequent to uptake into enterocytes, free cholesterol is esterified by the enzyme acyl-CoA:cholesterol acyltransferase and incorporated into chylomicrons, which leave the intestine through the lymphatic system.[36] In the circulation, chylomicrons are depleted of triglycerides and acquire apolipoprotein E (APOE), rendering these particles chylomicron remnants, which are internalized by hepatocytes following binding to the apolipoprotein B/E receptor (low-density lipoprotein receptor, LDLR) and the LDLR-related protein (LRP1).[31] Most cholesterol in gallstones appears to be of dietary origin,[9] underscoring the importance of intestinal cholesterol absorption for cholesterol gallstone formation.

After hepatocellular uptake, cholesterol can be stored as cholesteryl esters, routed to synthesis and secretion of very low density lipoproteins (VLDL), utilized for bile salt synthesis, or directed to biliary secretion. The secretion of cholesterol into bile depends on the action of the ABCG5/ABCG8 heterodimer, a transporter that is located on the canalicular membrane of hepatocytes.[37] The rate of bile salt synthesis is controlled by the activity of cholesterol 7α-hydroxylase (CYP7A1), the rate-limiting enzyme in the neutral pathway of bile salt synthesis.[24] Biliary secretion of bile salts involves the bile salt export pump (BSEP), encoded by the ABCB11 gene.[38] Bile salts are efficient detergents that facilitate hepatic secretion and intestinal absorption of cholesterol. Bile salts undergo an efficient enterohepatic circulation, including intestinal uptake by the sodium-dependant bile salt transporter ASBT (encoded by the SLC10A2 gene) and the basolateral hepatocellular uptake by the sodium/taurocholate cotransporting polypeptide NTCP (encoded by the SLC10A1 gene).[24] Finally, biliary phospholipids-principally phosphatidylcholine from de novo synthesis-are secreted into bile by the multiple drug resistance protein 3 (MDR3) encoded by ABCB4, another member of the ABC transporter family located on the canalicular membrane of hepatocytes.[39]

A network of nuclear receptors that are each characterized by heterodimerization with the retinoid X receptor (RXR), which is encoded by NR2B1 and activated by retinoids, regulates the metabolism of cholesterol and bile salts.[24] The nuclear lipid receptors include the liver X receptor (LXR) encoded by NR1H3. LXR is activated by oxysterols, and the LXR/RXR heterodimer induces expression of ABCG5/ABCG8 and consequently increases secretion of cholesterol into bile.[40] Another member of the nuclear sterol receptor family is the farnesoid X receptor (FXR) encoded by NR1H4, which is activated by bile salts and, following heterodimerization with RXR, induces expression of ABCB11 and inhibits expression of CYP7A1, leading to reduced hepatic bile salt synthesis and augmented biliary bile salt secretion.[40]

Cholesterol is only sparingly soluble in an aqueous medium such as bile and therefore kept in solution in vesicles with phospholipids or in mixed micelles with bile salts and phospholipids. Pioneering work by Admirand and Small revealed that it is the relative composition of bile salts, phospholipids, and cholesterol that determines the solubility of cholesterol in bile.[41] Bile becomes supersaturated with cholesterol when the biliary concentration of cholesterol is increased or the concentrations of bile salts or phospholipids, or both, are decreased, and the cholesterol saturation index (CSI) predicts whether the concentration of cholesterol exceeds the maximum concentration that is soluble at the given concentration of bile salts and phospholipids in bile.[42] However, even though supersaturation of bile with cholesterol is necessary for cholesterol gallstone formation, it is not sufficient.[1] Precipitation of cholesterol crystals and growth of cholesterol gallstones in supersaturated bile in most instances occur in a dysfunctional gallbladder with impaired gallbladder contraction leading to stasis of bile in the gallbladder.[43] Gallbladder emptying is essentially mediated by postprandial release of cholecystokinin A (CCKA) from specialized cells in the intestine and the binding to its receptor (CCKAR) expressed on gallbladder smooth muscle cells.[44] Furthermore, the secretion of mucin proteins from gallbladder epithelium cells precedes the precipitation of cholesterol crystals in gallbladder bile.[45] Mucins are sparingly soluble glycoproteins that are a major constituent of biliary sludge and act as a nucleating matrix and promote cholesterol crystallization and gallstone growth.[46] The major human mucin genes expressed by gallbladder epithelial cells are mucin 3, mucin 5b, and mucin 6, encoded by MUC3, MUC5B, and MUC6, respectively.[47] An overview of genes that may be involved in susceptibility to cholesterol gallstone formation and their role in lipid metabolism has been compiled.[48]

Recently, a study in inbred mice suggested that infection with Helicobacter species promotes mucin secretion and gallstone formation through inflammatory responses in the gallbladder.[49] Several lines of evidence suggest that in addition to infection with Helicobacter species, responses of the immune system leading to inflammatory processes contribute to each of the three pathophysiological cornerstones of cholesterol gallstone formation: (1) biliary supersaturation with cholesterol, (2) gallbladder hypomotility, and (3) nucleation of cholesterol crystals.[50] Fig. [1] displays a general model regarding the influence of genetic factors, environmental risk factors, and inflammatory responses that contribute to the susceptibility to cholesterol gallstone formation.

Oligogenic Predisposition to Cholelithiasis

As indicated previously, in the general population gallstone formation is a complex genetic trait that involves the effects of susceptible alleles of multiple LITH genes and their interactions with environmental influences.[8] However, in a small subgroup of gallstone carriers, mutations in single genes were identified, which result in a high risk of gallstone formation (Table [1]). In these subjects, the proportion of environmental factors that contribute to gallstone susceptibility is likely to be considerably smaller than in subjects displaying the common, complex pathogenesis of cholelithiasis (Fig. [2]). Nevertheless, even in the rare cases with a strong association of cholelithiasis to a single gene mutation, effects of additional modifier genes most likely affect the risk of gallstone development. Consequently, we refer to this form of genetic susceptibility as oligogenic cholelithiasis (Fig. [2]).

1 Quantitative trait locus.

2 Name of the QTL (Chr = chromosome, cM = centimorgan of the 95% confidence interval).

3 Gallbladder disease locus.

Chronic hemolysis increases the amount of unconjugated bilirubin in plasma. The augmented quantity of unconjugated bilirubin that is transported to the liver and undergoes hepatocellular uptake leads to increased secretion of bilirubin conjugates into bile.[51] Therefore, chronic hemolysis is associated with the formation of black pigment gallstones.[52] Accordingly, mutations in genes that result in chronic hemolysis such as thalassemia, hereditary spherocytosis, and sickle cell anemia are associated with calcium bilirubinate cholelithiasis.[8] In addition to hemolysis, induced enterohepatic cycling of bilirubin was proposed as another pathophysiological mechanism that increases the amount of unconjugated bilirubin delivered to the liver.[53] Systematic studies in the mouse model of cystic fibrosis suggest that mutations of the CFTR gene result in decreased intestinal uptake of bile salts and their spillage into the colon, leading to induced colonic bilirubin uptake.[54] In addition, a lower than normal pH in bile of cystic fibrosis mice was demonstrated to result in increased deconjugation of biliary bilirubin conjugates. In combination, these findings of the mouse model explain by inference the increased gallstone susceptibility in cystic fibrosis patients compared with matched controls.[55] A reduction in the capacity of the liver to conjugate bilirubin because of a common UGT1A1 promoter polymorphism underlies Gilbert's syndrome, which is characterized by increased proportions of unconjugated and monoglucuronidated biliary bilirubins.[56] In support of the concept of modifier genes in oligogenic cholelithiasis, this UGT1A1 polymorphism increases the susceptibility to gallstone formation in patients with cystic fibrosis[57] and chronic hereditary hemolytic anemias such as hereditary spherocytosis,[58] sickle cell anemia,[59] and thalassemia.[60]

In chronic liver diseases, the capacity of the liver to glucuronidate bilirubin is reduced and, furthermore, the biliary secretion of bile salts is impaired, explaining the increased formation of bilirubin gallstones in liver cirrhosis.[61] Cholelithiasis is associated positively with the severity of liver disease but apparently not influenced by the cause of cirrhosis.[61] [62] Accordingly, the prevalence of cholelithiasis was increased in both alcoholic cirrhosis and hereditary hemochromatosis, a hereditary cause of iron overload and liver cirrhosis related to polymorphisms in the HFE gene.[63] However, the additional influence of environmental factors to the gallstone risk in patients with hemochromatosis appeared to be small,[62] as expected for an oligogenic predisposition to cholelithiasis (Fig. [2]). Wilson's disease is another hereditary disorder that leads to liver cirrhosis and appears to be associated with increased gallstone prevalence rates.[64] Wilson's disease is due to copper accumulation caused by mutations in the ATB7B gene, and most likely both impaired liver function and increased hemolysis in a subset of patients with Wilson's disease lead to an increased risk of pigment stone formation. In summary, black pigment stone development is associated with genetic disorders that result in hemolysis and chronic liver disease. The common pathophysiological links between these genetic disorders and gallstone formation are the increased amount of unconjugated bilirubin delivered to the liver and the reduced capacity of the liver to conjugate bilirubin.

In the past several years, the genetic basis of different rare inherited forms of progressive intrahepatic cholestasis (PFIC type 1-3) was elucidated (see Trauner et al in this issue). PFIC type 1 is caused by mutations of the ATP8B1 gene encoding a canalicular aminophospholipid flippase, whereas PFIC type 2 and PFIC type 3 originate from homozygous mutations of ABCB11 and ABCB4, which lead to complete deficiency of the encoded canalicular phospholipid and bile salt transporters, respectively.[65] Cholelithiasis seems to be part of the disease spectrum in children with PFIC type 3,[66] whereas PFIC type 1 does not appear to be associated with gallstone formation. Milder forms of cholestasis with a recurrent rather than a progressive course of the disease (“benign” recurrent intrahepatic cholestasis, BRIC) are caused by mutations of ATP8B1 (BRIC 1) or ABCB11 (BRIC 2) that differ from the mutations that result in the more severe PFIC types 1 and 2.[65] In contrast to patients with BRIC 1, who do not seem to be at risk for gallstone formation, cholelithiasis was present in 7 of the 11 patients with BRIC 2 related to ABCB11 mutations.[67]

To date, the most compelling example of an oligogenic genetic susceptibility to gallstone formation is the ABCB4 deficiency syndrome. In this syndrome, mutations of the ABCB4 gene were identified in patients who were not diagnosed with PFIC type 3 but were characterized by younger age, positive family history for gallstones and intrahepatic cholestasis of pregnancy, recurrence of gallstones after cholecystectomy, and occurrence of intrahepatic sludge or microlithiasis.[68] Consonant with the function of the encoded protein as a biliary phospholipid transporter, mutations of ABCB4 were shown in a few patients to be associated with a low phospholipid concentration in bile and, consequently, a high CSI.[69] The underlying pathophysiological mechanisms of this low phospholipid-associated cholelithiasis syndrome were elucidated further by studies in ABCB4-deficient mice that displayed spontaneous occurrence of cholesterol gallstones.[70]

In a screen for high plasma cholesterol levels, one family was identified to have members affected by hypertriglyceridemia and hypercholesterolemia, low fecal bile salt excretion, and gallstone formation.[71] These abnormalities were explained by mutations in the CYP7A1 gene that rendered the encoded enzyme dysfunctional.[71] Continuation of screening detected additional CYP7A1 variants that were associated with cholelithiasis in a small proportion of patients.[72] Although mutations in the CYP7A1 gene explain gallstone susceptibility in a minor subset of patients only, these findings confirm impaired degradation of cholesterol into bile salts as a potential pathophysiological mechanism of cholesterol cholelithiasis. Further support for this conclusion is derived from studies in Cyp7a1 transgenic mice, which are resistant to cholesterol gallstone development induced by a high-fat diet.[73] In addition, gallstone formation was reported as part of the disease spectrum in hypobetalipoproteinemia, a rare disorder caused by mutations in the APOB gene that is characterized by low plasma levels of cholesterol, HDL, and apolipoprotein B.[74]

In another isolated case of cholelithiasis, a deletion of the third exon of the CCKAR gene was identified.[75] An association of altered CCKAR structure and gallstone formation was supported by a functional in vitro study,[76] and a subsequent study detected lower CCKAR gene expression in gallbladders with gallstones compared with gallbladders without gallstones.[77] CCKAR mutations resulting in cholelithiasis appear to be exceptionally rare. However, somatostatin and octreotide inhibit postprandial CCK release from the gastrointestinal tract, and an important role of CCK and its receptor in gallstone formation is underscored by high gallstone prevalence rates in patients with somatostatinoma[78] and in patients treated with octreotide.[79] Further support for this conclusion is derived from findings in CCKAR-deficient mice, which show gallbladder hypomotility and prolonged small intestinal transit times, resulting in stasis of bile in the gallbladder and increased intestinal cholesterol absorption.[44]

In conclusion, mutations were unraveled in a small number of genes affecting hepatic cholesterol metabolism, canalicular lipid transport, and motility of the gallbladder and the small intestine, leading to a substantial risk of gallstone formation in selected patients (Table [1]). Even though these mutations do not explain susceptibility to gallstone formation in the majority of patients, they provide insight into cornerstones of the underlying pathophysiology of cholelithiasis (the putative mechanisms are summarized in Table [1]).

“Common” Polygenic Predisposition to Gallstones

It is well established that part of the susceptibility to cholelithiasis is genetically determined (Fig. [1]); however, knowledge of the LITH genes involved along with their underlying lithogenic polymorphisms that increase the gallstone risk in the majority of gallstone patients remains elusive. Up to now, the results of only one linkage study were reported. This study performed a genome-wide scan of polymorphic markers at an average distance of 10 cM in Mexican-American families who were part of the San Antonio Family Diabetes/Gallbladder Study.[80] Two loci on chromosome 1p were linked significantly to symptomatic gallstone disease in the entire study cohort including both diabetic and nondiabetic subjects (Table [2]). Furthermore, additional loci displayed suggestive linkage to cholelithiasis both in the group of diabetic and nondiabetic subjects and in the cohort of nondiabetic subjects only.[80] Caveats of this analysis are the exceptional study population, comprising a large proportion of diabetic individuals, and the distinct loci detected for symptomatic gallstone disease only or symptomatic and asymptomatic cholelithiasis combined, which render some of the results difficult to interpret. Clearly, additional genome-wide linkage or association studies are warranted as a hypothesis-free approach to identify genomic regions associated with gallstone formation in different populations.

4 Name of the QTL (Chr = chromosome, cM = centimorgan of the 95% confidence interval).

5 Gallbladder disease locus.

In a study aimed at dissecting the genetic determinants of HDL cholesterol levels, it was reported that polymorphisms of genes that display an oligogenic association with a trait also contribute to phenotypic variation in the general population.[81] Consistent with this novel concept, a study from China detected an association of a single nucleotide polymorphism (SNP) within the CYP7A1 promoter with gallstones.[82] In addition, significant associations of a common polymorphism of the APOB gene with gallstone prevalence have been reported in two Chinese populations.[82] [83] However, the association was not confirmed in studies from Finland and India,[84] [85] findings that may reflect ethnic differences between study populations. In contrast to the positive results of studies for CYP7A1 and APOB, association studies for ABCB11,[86] ABCB4,[68] and CCKAR [77] premising that each of these genes confers oligogenic gallstone susceptibility revealed negative results and did not confirm an association with common cholelithiasis in the populations studied.

The association of genetic variation between APOE alleles and susceptibility to gallstone formation is the one investigated most extensively to date. Three different common APOE alleles, (ε2, ε3 and ε4) exist and the encoded isoforms of APOE differ in their affinities to the APOE receptor.[87] Possibly because of higher hepatic uptake of lipoproteins carrying the E4 isoform, initial studies observed an association of the ε4 allele of APOE and higher cholesterol content of gallstones,[88] higher gallstone prevalence rates,[89] recurrence of gallstones after extracorporeal shock wave lithotripsy,[90] and cholesterol versus pigment gallstones in a small number of patients.[91] Furthermore, one study found that the ε2 allele may protect against gallstone formation in women.[92] However, the association of APOE alleles and gallstones was not confirmed in larger follow-up studies in Chile, Germany, India, Japan, and China[82] [93] [94]-again, an observation that may be explained by different ethnicities, dietary habits, and age ranges of study participants. In addition to the association of cholelithiasis and APOE, one small study reported an association of polymorphism of CETP and gallstone susceptibility,[84] whereas this finding was not confirmed in studies from India, which detected associations of LRPAP1 and APOCI polymorphisms and cholelithiasis in females but not in males.[94] [95] [96] The studies that identified an association of gallstone prevalence and genetic variation in a single cohort await confirmation from analyses in independent populations.

An inbred mouse model of cholelithiasis might facilitate the identification of LITH genes in humans. Genomic regions associated with gallstone susceptibility and several positional candidate genes were identified in a series of quantitative trait locus (QTL) crosses in inbred mice.[48] [97] Comparison of draft sequences of mouse and human genomes confirmed that more than 90% of the mouse genome has corresponding regions of conserved synteny in the human genome. These homologous segments with preserved gene order that were not disrupted by rearrangements during evolution are distributed randomly within the genome.[98] Comparison of map positions of susceptibility loci for complex diseases from studies in humans with the results of QTL analyses in the corresponding mouse models of the diseases revealed that the majority of susceptibility loci for complex traits appear to be located in homologous genomic regions among species.[99] [100] [101] The concept is supported further by the growing number of examples of susceptibility genes that were proved to contain polymorphisms that are associated with a trait in both species.[102] [103] Therefore, it appears to be a promising strategy to identify Lith genes in the murine model of cholelithiasis and test these genes in directed studies in humans.[97] However, this hypothesis remains to be proved because the only two studies that employed this concept to date revealed negative results for ABCB11 and LXRA, which are positional candidate genes for the murine gallstone susceptibility locus Lith1, and APOBEC1 and PPARG as candidates for Lith6.[86] [104]

FUTURE STRATEGIES FOR PREVENTION AND TREATMENT OF GALLBLADDER STONES BASED ON THE GENETIC PREDISPOSITION TO GALLBLADDER STONES

The epidemiological, family, and twin studies in humans as well as the genetic studies in mice unambiguously confirmed that cholelithiasis is a complex disorder caused by genetic and environmental factors. Nevertheless, to date this perception has not led to novel strategies in the clinical approach to cholelithiasis. Consequently, at present cholecystectomy remains the mainstay of treatment of symptomatic gallstones, whereas asymptomatic gallstones, in most cases, are managed with observation.[1] The last substantial innovation in the conservative management of gallstones was derived from unraveling the physical-chemical background of cholesterol cholelithiasis. However, the resulting therapy for gallstone dissolution with ursodeoxycholic acid (UDCA), a hydrophilic bile acid, was largely abandoned because of the long duration of drug treatment and frequent recurrence of gallstones.[105] Genetic studies may facilitate the identification of the true pathophysiology of gallstone formation and disclose novel directions for targeted strategies in the management of cholelithiasis. However, to break these new grounds, the principal human LITH genes and the genetic mechanisms involved will need to be unraveled.

In the future, individual risk profiling may allow distinguishing between moderate- and high-risk groups of patients. These risk profiles will probably include both genetic factors (e.g., ABCB4 mutations[68]) and environmental factors. One example of a possible interaction between genetic and environmental risk factors is the recent observation that a polymorphism of CYP17, encoding a key enzyme of estrogen metabolism, increases the risk of gallstone formation in patients with a higher body mass index or a history of diabetes only.[106] Primary preventive measures for individuals at moderate risk for symptoms or complications may include weight reduction and modifications of lifestyle and diet. In contrast, patients at high risk could be offered specific drugs for prevention or even prophylactic cholecystectomy, which was recently confirmed to be a safe procedure in the treatment of patients younger than 50 years with asymptomatic gallstones.[107] Currently, extracorporeal shock wave lithotripsy (ESWL) of gallbladder stones is largely abandoned and replaced by laparoscopic cholecystectomy. However, if recurrence of gallstones could be prevented by targeted drug therapy or improved selection of patients, this method may be revived as an acceptable therapeutic option.[108] Selection of patients who may benefit from nonsurgical management of gallbladder stones may involve the exclusion of patients with a strong genetic susceptibility to gallstone formation and hence a high risk of recurrence. In contrast, patients who carry gallbladder stones that were driven in their development by environmental factors, such as diet or rapid weight loss, may have a low risk for the recurrence of gallstones when the triggering factors are controlled. One example in support of prophylactic therapy of cholelithiasis is asymptomatic family members of LPAC patients who carry ABCB4 mutations and may benefit from preventive treatment with UDCA.[68] An example for avenues to improved selection of patients for nonsurgical management of gallbladder stones is the notion that carriers of the APOE4 allele possess an increased risk for the recurrence of gallstones following ESWL.[90] However, to date these strategies are speculative and will require extensive basic research to identify promising targets as well as substantial clinical evaluation.

At the moment, UDCA is the single therapeutic agent used for prevention or dissolution of cholesterol gallstones.[109] However, current knowledge suggests additional strategies for conservative management of gallstones. Agonists that selectively induce ABC transporters may be developed to decrease the lithogenicity of bile by altering the relative lipid composition.[110] Furthermore, the putative role of infection with Helicobacter species[49] and inflammatory responses[50] in the formation of cholesterol gallstones suggests that antibiotics to eradicate enterohepatic Helicobacter species could be antilithogenic and prevent the formation of cholesterol gallstones.

With respect to pigment stones, nontoxic drugs for the treatment of hereditary or acquired hypersecretion of bilirubin into bile remain to be developed. Previous attempts to decrease the enterohepatic circulation of unconjugated bilirubin included the administration of agents that trapped unconjugated bilirubin in the intestine by absorption to nonabsorbable solids or by forming insoluble salts of bilirubinate with calcium.[111] [112] Other approaches employed the administration of zinc.[113] [114] In addition, the lipase inhibitor orlistat, which increases intestinal and fecal fat contents, was demonstrated to enhance fecal bilirubin excretion and to decrease serum bilirubin levels in Gunn rats.[112] Although efficacy of this agent in humans has yet to be investigated, this drug might also antagonize other “thrifty” phenotypes of patients with metabolic syndrome. Finally, norursodeoxycholic acid, the C23-synthetic homologue of UDCA without the C24 methylene group of the side chain,[115] has been shown to induce bicarbonate-rich choleresis and to reduce bilirubin precipitation in bile in the murine model of cystic fibrosis.[54]

In the future, genome-wide association studies in different populations are likely to identify the entire set of common LITH genes. As the disease phenotype results from the manifestation of genetic susceptibility factors under the influence of environmental triggers, discovery of LITH genes will open avenues to control the influence of environmental challenges on the risk of gallstone formation. When the underlying LITH genes are defined, this most likely will lead to the design of novel interventions to extend our currently limited strategies for risk assessment and prevention of gallstone formation and facilitate the identification of targets for nonsurgical management of this exceptionally prevalent digestive disease.

ACKNOWLEDGMENTS

The authors' experimental work related to the genetic background of gallstone formation has been supported by research grants from the Deutsche Forschungsgemeinschaft.

ABBREVIATIONS

• ABC ATP-binding cassette

• APOE apolipoprotein E

• ATP adenosine triphosphate

• BRIC benign recurrent intrahepatic cholestasis

• BSEP bile salt export pump

• CCKA cholecystokinin A

• CETP cholesteryl ester transfer protein

• CFTR cystic fibrosis transmembrane conductance regulator

• FXR farnesoid X receptor

• HDL high-density lipoprotein

• HLA human leukocyte antigen

• HMG-CoA 3-hydroxy-3-methylglutaryl coenzyme A

• LDL low-density lipoprotein

• LDLR LDL receptor

• LRP1 LDLR-related protein 1

• LXR liver X receptor

• MDR3 multiple drug resistance protein 3

• MRP2 multiple resistance-related protein 2

• NPC1L1 Niemann-Pick C1-like protein 1

• QTL quantitative trait locus

• RXR retinoid X receptor

• SCARB1 scavenger receptor B-1

• UDCA ursodeoxycholic acid

• VLDL very low-density lipoprotein

REFERENCES

• 1 Portincasa P, Moschetta A, Palasciano G. Cholesterol gallstone disease.  Lancet. 2006;  368 230-239
  CrossrefPubMedSearch in Google Scholar
• 2 Cahalane M J, Neubrand M W, Carey M C. Physical-chemical pathogenesis of pigment gallstones.  Semin Liver Dis. 1988;  8 317-328
  Thieme ConnectPubMedSearch in Google Scholar
• 3 Robins S J, Fasulo J M, Patton G M. Lipids of pigment gallstones.  Biochim Biophys Acta. 1982;  712 21-25
  PubMedSearch in Google Scholar
• 4 Wosiewitz U, Schenk J, Sabinski F, Schmack B. Investigations on common bile duct stones.  Digestion. 1983;  26 43-52
  PubMedSearch in Google Scholar
• 5 Friedman G D. Natural history of asymptomatic and symptomatic gallstones.  Am J Surg. 1993;  165 399-404
  CrossrefPubMedSearch in Google Scholar
• 6 Sandler R S, Everhart J E, Donowitz M et al.. The burden of selected digestive diseases in the United States.  Gastroenterology. 2002;  122 1500-1511
  CrossrefPubMedSearch in Google Scholar
• 7 Kratzer W, Mason R A, Kachele V. Prevalence of gallstones in sonographic surveys worldwide.  J Clin Ultrasound. 1999;  27 1-7
  CrossrefPubMedSearch in Google Scholar
• 8 Lammert F, Sauerbruch T. Mechanisms of disease: the genetic epidemiology of gallbladder stones.  Nat Clin Pract Gastroenterol Hepatol. 2005;  2 423-433
  PubMedSearch in Google Scholar
• 9 Paigen B, Carey M C. Gallstones. In: King RA, Rotter JF, Motulsky AG The Genetic Basis of Common Diseases. 2nd ed. New York; Oxford University Press 2002: 298-335
  Search in Google Scholar
• 10 Sampliner R E, Bennett P H, Comess L J, Rose F A, Burch T A. Gallbladder disease in Pima Indians: demonstration of high prevalence and early onset by cholecystography.  N Engl J Med. 1970;  283 1358-1364
  PubMedSearch in Google Scholar
• 11 Everhart J E, Yeh F, Lee E T et al.. Prevalence of gallbladder disease in American Indian populations: findings from the Strong Heart Study.  Hepatology. 2002;  35 1507-1512
  CrossrefPubMedSearch in Google Scholar
• 12 Everhart J E, Khare M, Hill M, Maurer K R. Prevalence and ethnic differences in gallbladder disease in the United States.  Gastroenterology. 1999;  117 632-639
  CrossrefPubMedSearch in Google Scholar
• 13 Mendez-Sanchez N, King-Martinez A C, Ramos M H, Pichardo-Bahena R, Uribe M. The Amerindian's genes in the Mexican population are associated with development of gallstone disease.  Am J Gastroenterol. 2004;  99 2166-2170
  CrossrefPubMedSearch in Google Scholar
• 14 Miquel J F, Covarrubias C, Villaroel L et al.. Genetic epidemiology of cholesterol cholelithiasis among Chilean Hispanics, Amerindians, and Maoris.  Gastroenterology. 1998;  115 937-946
  CrossrefPubMedSearch in Google Scholar
• 15 Carey M C, Paigen B. Epidemiology of the American Indians' burden and its likely genetic origins.  Hepatology. 2002;  36 781-791
  PubMedSearch in Google Scholar
• 16 Neel J V. Diabetes mellitus: a “thrifty” genotype rendered detrimental by “progress”?.  Am J Hum Genet. 1962;  14 353-362
  PubMedSearch in Google Scholar
• 17 Attili A F, Capocaccia R, Carulli N et al.. Factors associated with gallstone disease in the MICOL experience. Multicenter Italian Study on Epidemiology of Cholelithiasis.  Hepatology. 1997;  26 809-818
  CrossrefPubMedSearch in Google Scholar
• 18 Tsai C J, Leitzmann M F, Willett W C, Giovannucci E L. Glycemic load, glycemic index, and carbohydrate intake in relation to risk of cholecystectomy in women.  Gastroenterology. 2005;  129 105-112
  CrossrefPubMedSearch in Google Scholar
• 19 Lowenfels A B. Gallstones and glaciers: the stone that came in from the cold.  Lancet. 1988;  1 1385-1386
  PubMedSearch in Google Scholar
• 20 Barbara L, Sama C, Morselli Labate A M et al.. A population study on the prevalence of gallstone disease: the Sirmione Study.  Hepatology. 1987;  7 913-917
  CrossrefPubMedSearch in Google Scholar
• 21 Nakeeb A, Comuzzie A G, Martin L et al.. Gallstones: genetics versus environment.  Ann Surg. 2002;  235 842-849
  CrossrefPubMedSearch in Google Scholar
• 22 Katsika D, Grjibovski A, Einarsson C et al.. Genetic and environmental influences on symptomatic gallstone disease: a Swedish study of 43,141 twin pairs.  Hepatology. 2005;  41 1138-1143
  CrossrefPubMedSearch in Google Scholar
• 23 Duggirala R, Mitchell B D, Blangero J, Stern M P. Genetic determinants of variation in gallbladder disease in the Mexican-American population.  Genet Epidemiol. 1999;  16 191-204
  CrossrefPubMedSearch in Google Scholar
• 24 Kullak-Ublick G A, Stieger B, Meier P J. Enterohepatic bile salt transporters in normal physiology and liver disease.  Gastroenterology. 2004;  126 322-342
  CrossrefPubMedSearch in Google Scholar
• 25 Hofmann A F. Bile acid secretion, bile flow and biliary lipid secretion in humans.  Hepatology. 1990;  12 17S-22S discussion 22S-25S
  PubMedSearch in Google Scholar
• 26 Baiocchi L, LeSage G, Glaser S, Alpini G. Regulation of cholangiocyte bile secretion.  J Hepatol. 1999;  31 179-191
  CrossrefPubMedSearch in Google Scholar
• 27 Wang P, Kim R B, Chowdhury J R, Wolkoff A W. The human organic anion transport protein SLC21A6 is not sufficient for bilirubin transport.  J Biol Chem. 2003;  278 20695-20699
  CrossrefPubMedSearch in Google Scholar
• 28 Bosma P J, Seppen J, Goldhoorn B et al.. Bilirubin UDP-glucuronosyltransferase 1 is the only relevant bilirubin glucuronidating isoform in man.  J Biol Chem. 1994;  269 17960-17964
  PubMedSearch in Google Scholar
• 29 Nies A T, Keppler D. The apical conjugate efflux pump ABCC2 (MRP2).  Pflugers Arch. 2006;  , July 18 (Epub ahead of print)
  PubMedSearch in Google Scholar
• 30 Robins S J, Fasulo J M. High density lipoproteins, but not other lipoproteins, provide a vehicle for sterol transport to bile.  J Clin Invest. 1997;  99 380-384
  PubMedSearch in Google Scholar
• 31 Cooper A D. Hepatic uptake of chylomicron remnants.  J Lipid Res. 1997;  38 2173-2192
  PubMedSearch in Google Scholar
• 32 Hillebrant C G, Nyberg B, Einarsson K, Eriksson M. The effect of plasma low density lipoprotein apheresis on the hepatic secretion of biliary lipids in humans.  Gut. 1997;  41 700-704
  PubMedSearch in Google Scholar
• 33 Caroli-Bosc F X, Le Gall P, Pugliese P et al.. Role of fibrates and HMG-CoA reductase inhibitors in gallstone formation: epidemiological study in an unselected population.  Dig Dis Sci. 2001;  46 540-544
  CrossrefPubMedSearch in Google Scholar
• 34 Tall A R, Wang N, Mucksavage P. Is it time to modify the reverse cholesterol transport model?.  J Clin Invest. 2001;  108 1273-1275
  CrossrefPubMedSearch in Google Scholar
• 35 Ji Y, Wang N, Ramakrishnan R et al.. Hepatic scavenger receptor BI promotes rapid clearance of high density lipoprotein free cholesterol and its transport into bile.  J Biol Chem. 1999;  274 33398-33402
  CrossrefPubMedSearch in Google Scholar
• 36 Lammert F, Wang D Q. New insights into the genetic regulation of intestinal cholesterol absorption.  Gastroenterology. 2005;  129 718-734
  CrossrefPubMedSearch in Google Scholar
• 37 Yu L, Hammer R E, Li-Hawkins J et al.. Disruption of Abcg5 and Abcg8 in mice reveals the crucial role in biliary cholesterol secretion.  Proc Natl Acad Sci USA. 2002;  99 16237-16242
  CrossrefPubMedSearch in Google Scholar
• 38 Wang R, Salem M, Yousef I M et al.. Targeted inactivation of sister of P-glycoprotein gene (spgp) in mice results in nonprogressive but persistent intrahepatic cholestasis.  Proc Natl Acad Sci USA. 2001;  98 2011-2016
  CrossrefPubMedSearch in Google Scholar
• 39 Smit J J, Schinkel A H, Oude Elferink R P et al.. Homozygous disruption of the murine mdr2 gene P-glycoprotein gene leads to a complete absence of phospholipid from bile and to liver disease.  Cell. 1993;  75 451-462
  CrossrefPubMedSearch in Google Scholar
• 40 Kalaany N Y, Mangelsdorf D J. LXRS and FXR: the yin and yang of cholesterol and fat metabolism.  Annu Rev Physiol. 2006;  68 159-191
  CrossrefPubMedSearch in Google Scholar
• 41 Admirand W H, Small D M. The physicochemical basis of cholesterol gallstone formation in man.  J Clin Invest. 1968;  47 1043-1052
  CrossrefPubMedSearch in Google Scholar
• 42 Carey M C. Critical tables for calculating the cholesterol saturation of native bile.  J Lipid Res. 1978;  19 945-955
  PubMedSearch in Google Scholar
• 43 Portincasa P, Di Ciaula A, vanBerge-Henegouwen G P. Smooth muscle function and dysfunction in gallbladder disease.  Curr Gastroenterol Rep. 2004;  6 151-162
  PubMedSearch in Google Scholar
• 44 Wang D Q, Schmitz F, Kopin A S, Carey M C. Targeted disruption of the murine cholecystokinin-1 receptor promotes intestinal cholesterol absorption and susceptibility to cholesterol cholelithiasis.  J Clin Invest. 2004;  114 521-528
  CrossrefPubMedSearch in Google Scholar
• 45 Marks J W, Bonorris G G, Albers G, Schoenfield L J. The sequence of biliary events preceding the formation of gallstones in humans.  Gastroenterology. 1992;  103 566-570
  PubMedSearch in Google Scholar
• 46 Wilhelmi M, Jungst C, Mock M et al.. Effect of gallbladder mucin on the crystallization of cholesterol in bile.  Eur J Gastroenterol Hepatol. 2004;  16 1301-1307
  CrossrefPubMedSearch in Google Scholar
• 47 Vandenhaute B, Buisine M P, Debailleul V et al.. Mucin gene expression in biliary epithelial cells.  J Hepatol. 1997;  27 1057-1066
  PubMedSearch in Google Scholar
• 48 Lammert F, Carey M C, Paigen B. Chromosomal organization of candidate genes involved in cholesterol gallstone formation: a murine gallstone map.  Gastroenterology. 2001;  120 221-238
  CrossrefPubMedSearch in Google Scholar
• 49 Maurer K J, Ihrig M M, Rogers A B et al.. Identification of cholelithogenic enterohepatic helicobacter species and their role in murine cholesterol gallstone formation.  Gastroenterology. 2005;  128 1023-1033
  CrossrefPubMedSearch in Google Scholar
• 50 Lyons M A, Wittenburg H. Susceptibility to cholesterol gallstone formation: evidence that LITH genes also encode immune-related factors.  Biochim Biophys Acta. 2006;  1761 1133-1147
  PubMedSearch in Google Scholar
• 51 Trotman B W, Bernstein S E, Balistreri W F, Wirt G D, Martin R A. Hemolysis-induced gallstones in mice: increased unconjugated bilirubin in hepatic bile predisposes to gallstone formation.  Gastroenterology. 1981;  81 232-236
  PubMedSearch in Google Scholar
• 52 Soloway R D, Trotman B W, Maddrey W C, Nakayama F. Pigment gallstone composition in patients with hemolysis or infection/stasis.  Dig Dis Sci. 1986;  31 454-460
  CrossrefPubMedSearch in Google Scholar
• 53 Vitek L, Carey M C. Enterohepatic cycling of bilirubin as a cause of “black” pigment gallstones in adult life.  Eur J Clin Invest. 2003;  33 799-810
  CrossrefPubMedSearch in Google Scholar
• 54 Broderick A L, Wittenburg H, Lyons M A et al.. Cystic fibrosis transmembrane conductance regulator gene mutations cause “black” pigment gallstone formation: new insights from mouse models and implications for therapeutic interventions in cystic fibrosis. In: Adler G, Blum HE, Fuchs M, Stange EF Gallstones: Pathogenesis and Treatment. Dordrecht/Boston/London; Kluwer Academics Publishers 2004: 24-27
  Search in Google Scholar
• 55 Angelico M, Gandin C, Canuzzi P et al.. Gallstones in cystic fibrosis: a critical reappraisal.  Hepatology. 1991;  14 768-775
  CrossrefPubMedSearch in Google Scholar
• 56 Fevery J, Blanckaert N, Heirwegh K P, Preaux A M, Berthelot P. Unconjugated bilirubin and an increased proportion of bilirubin monoconjugates in the bile of patients with Gilbert's syndrome and Crigler-Najjar disease.  J Clin Invest. 1977;  60 970-979
  PubMedSearch in Google Scholar
• 57 Wasmuth H E, Keppeler H, Herrmann U et al.. Coinheritance of Gilbert syndrome-associated UGT1A1 mutation increases gallstone risk in cystic fibrosis.  Hepatology. 2006;  43 738-741
  CrossrefPubMedSearch in Google Scholar
• 58 del Giudice E M, Perrotta S, Nobili B et al.. Coinheritance of Gilbert syndrome increases the risk for developing gallstones in patients with hereditary spherocytosis.  Blood. 1999;  94 2259-2262
  PubMedSearch in Google Scholar
• 59 Chaar V, Keclard L, Diara J P et al.. Association of UGT1A1 polymorphism with prevalence and age at onset of cholelithiasis in sickle cell anemia.  Haematologica. 2005;  90 188-199
  PubMedSearch in Google Scholar
• 60 Premawardhena A, Fisher C A, Fathiu F et al.. Genetic determinants of jaundice and gallstones in haemoglobin E beta thalassaemia.  Lancet. 2001;  357 1945-1946
  CrossrefPubMedSearch in Google Scholar
• 61 Conte D, Fraquelli M, Fornari F et al.. Close relation between cirrhosis and gallstones: cross-sectional and longitudinal survey.  Arch Intern Med. 1999;  159 49-52
  CrossrefPubMedSearch in Google Scholar
• 62 Conte D, Barisani D, Mandelli C et al.. Prevalence of cholelithiasis in alcoholic and genetic haemochromatotic cirrhosis.  Alcohol Alcohol. 1993;  28 581-584
  PubMedSearch in Google Scholar
• 63 Zoller H, Cox T M. Hemochromatosis: genetic testing and clinical practice.  Clin Gastroenterol Hepatol. 2005;  3 945-958
  CrossrefPubMedSearch in Google Scholar
• 64 Walshe J M. Hepatic Wilson's disease: initial treatment and long-term management.  Curr Treat Options Gastroenterol. 2005;  8 467-472
  PubMedSearch in Google Scholar
• 65 Oude Elferink R P, Paulusma C C, Groen A K. Hepatocanalicular transport defects: pathophysiologic mechanisms of rare diseases.  Gastroenterology. 2006;  130 908-925
  CrossrefPubMedSearch in Google Scholar
• 66 Jacquemin E, De Vree J M, Cresteil D et al.. The wide spectrum of multidrug resistance 3 deficiency: from neonatal cholestasis to cirrhosis of adulthood.  Gastroenterology. 2001;  120 1448-1458
  CrossrefPubMedSearch in Google Scholar
• 67 van Mil S W, van der Woerd W L, van der Brugge G et al.. Benign recurrent intrahepatic cholestasis type 2 is caused by mutations in ABCB11.  Gastroenterology. 2004;  127 379-384
  CrossrefPubMedSearch in Google Scholar
• 68 Rosmorduc O, Hermelin B, Boelle P-Y et al.. ABCB4 gene mutation-associated cholelithiasis in adults.  Gastroenterology. 2003;  125 452-459
  CrossrefPubMedSearch in Google Scholar
• 69 Rosmorduc O, Hermelin B, Poupon R. MDR3 gene defect in adults with symptomatic intrahepatic and gallbladder cholesterol cholelithiasis.  Gastroenterology. 2001;  120 1459-1467
  CrossrefPubMedSearch in Google Scholar
• 70 Lammert F, Wang D Q, Hillebrandt S et al.. Spontaneous cholecysto- and hepatolithiasis in Mdr2 - / - mice: a model for low phospholipid-associated cholelithiasis.  Hepatology. 2004;  39 117-128
  CrossrefPubMedSearch in Google Scholar
• 71 Pullinger C R, Eng C, Salen G et al.. Human cholesterol 7alpha-hydroxylase (CYP7A1) deficiency has a hypercholesterolemic phenotype.  J Clin Invest. 2002;  110 109-117
  CrossrefPubMedSearch in Google Scholar
• 72 Pullinger C R, Eng C, Malloy M J, Kane J P. Cholesterol 7alpha-hydroxylase (CYP7A1) gene mutation: another cause for gallstone formation?. In: Adler G, Blum HE, Fuchs M, Stange EF Gallstones: Pathogenesis and Treatment. Dordrecht/Boston/London; Kluwer Academics Publishers 2004: 14-23
  Search in Google Scholar
• 73 Miyake J H, Duong-Polk X T, Taylor J M et al.. Transgenic expression of cholesterol-7-alpha-hydroxylase prevents atherosclerosis in C57BL/6J mice.  Arterioscler Thromb Vasc Biol. 2002;  22 121-126
  CrossrefPubMedSearch in Google Scholar
• 74 Lancellotti S, Zaffanello M, Di Leo E et al.. Pediatric gallstone disease in familial hypobetalipoproteinemia.  J Hepatol. 2005;  43 188-191
  CrossrefPubMedSearch in Google Scholar
• 75 Miller L J, Holicky E L, Ulrich C D, Wieben E D. Abnormal processing of the human cholecystokinin receptor gene in association with gallstones and obesity.  Gastroenterology. 1995;  109 1375-1380
  CrossrefPubMedSearch in Google Scholar
• 76 Schneider H, Sanger P, Hanisch E. In vitro effects of cholecystokinin fragments on human gallbladders: evidence for an altered CCK-receptor structure in a subgroup of patients with gallstones.  J Hepatol. 1997;  26 1063-1068
  CrossrefPubMedSearch in Google Scholar
• 77 Miyasaka K, Takata Y, Funakoshi A. Association of cholecystokinin A receptor gene polymorphism with cholelithiasis and the molecular mechanisms of this polymorphism.  J Gastroenterol. 2002;  37 102-106
  PubMedSearch in Google Scholar
• 78 Krejs G J, Orci L, Conlon J M et al.. Somatostatinoma syndrome: biochemical, morphologic and clinical features.  N Engl J Med. 1979;  301 285-292
  PubMedSearch in Google Scholar
• 79 Moschetta A, Stolk M F, Rehfeld J F et al.. Severe impairment of postprandial cholecystokinin release and gall-bladder emptying and high risk of gallstone formation in acromegalic patients during Sandostatin LAR.  Aliment Pharmacol Ther. 2001;  15 181-185
  CrossrefPubMedSearch in Google Scholar
• 80 Puppala S, Dodd G D, Fowler S et al.. A genomewide search finds major susceptibility loci for gallbladder disease on chromosome 1 in Mexican Americans.  Am J Hum Genet. 2006;  78 377-392
  CrossrefPubMedSearch in Google Scholar
• 81 Cohen J C, Kiss R S, Pertsemlidis A et al.. Multiple rare alleles contribute to low plasma levels of HDL cholesterol.  Science. 2004;  305 869-872
  CrossrefPubMedSearch in Google Scholar
• 82 Jiang Z Y, Han T Q, Suo G J et al.. Polymorphisms at cholesterol 7alpha-hydroxylase, apolipoproteins B and E and low density lipoprotein receptor genes in patients with gallbladder stone disease.  World J Gastroenterol. 2004;  10 1508-1512
  CrossrefPubMedSearch in Google Scholar
• 83 Han T, Jiang Z, Suo G, Zhang S. Apolipoprotein B-100 gene Xba I polymorphism and cholesterol gallstone disease.  Clin Genet. 2000;  57 304-308
  PubMedSearch in Google Scholar
• 84 Juvonen T, Savolainen M J, Kervinen K et al.. Polymorphism at the apoB, apoA-I, and the cholesterol ester transfer protein gene loci in patients with gallbladder disease.  J Lipid Res. 1995;  36 804-812
  PubMedSearch in Google Scholar
• 85 Singh M K, Pandey U B, Ghoshal U C et al.. Apolipoprotein B-100 XbaI gene polymorphism in gallbladder cancer.  Hum Genet. 2004;  114 280-283
  PubMedSearch in Google Scholar
• 86 Schafmayer C, Tepel J, Franke A et al.. Investigation of the Lith1 candidate genes ABCB11 and LXRA in human gallstone disease.  Hepatology. 2006;  44 650-657
  CrossrefPubMedSearch in Google Scholar
• 87 Weintraub M S, Eisenberg S, Breslow J L. Dietary fat clearance in normal subjects is regulated by genetic variation in apolipoprotein E.  J Clin Invest. 1987;  80 1571-1577
  PubMedSearch in Google Scholar
• 88 Juvonen T, Kervinen K, Kairaluoma M I, Lajunen L H, Kesaniemi Y A. Gallstone cholesterol content is related to apolipoprotein E polymorphism.  Gastroenterology. 1993;  104 1806-1813
  PubMedSearch in Google Scholar
• 89 Bertomeu A, Ros E, Zambon D et al.. Apolipoprotein E polymorphism and gallstones.  Gastroenterology. 1996;  111 1603-1610
  PubMedSearch in Google Scholar
• 90 Venneman N G, vanBerge-Henegouwen G P, Portincasa P et al.. Absence of apolipoprotein E4 genotype, good gallbladder motility and presence of solitary stones delay rather than prevent gallstone recurrence after extracorporeal shock wave lithotripsy.  J Hepatol. 2001;  35 10-16
  PubMedSearch in Google Scholar
• 91 van Erpecum K J, Portincasa P, Dohlu M H, van Berge-Henegouwen G P, Jungst D. Biliary pronucleating proteins and apolipoprotein E in cholesterol and pigment stone patients.  J Hepatol. 2003;  39 7-11
  CrossrefPubMedSearch in Google Scholar
• 92 Niemi M, Kervinen K, Rantala A et al.. The role of apolipoprotein E and glucose intolerance in gallstone disease in middle aged subjects.  Gut. 1999;  44 557-562
  PubMedSearch in Google Scholar
• 93 Hasegawa K, Terada S, Kubota K et al.. Effect of apolipoprotein E polymorphism on bile lipid composition and the formation of cholesterol gallstone.  Am J Gastroenterol. 2003;  98 1605-1609
  CrossrefPubMedSearch in Google Scholar
• 94 Dixit M, Choudhuri G, Mittal B. Association of APOE-C1 gene cluster polymorphisms with gallstone disease.  Dig Liver Dis. 2006;  38 397-403
  CrossrefPubMedSearch in Google Scholar
• 95 Dixit M, Choudhuri G, Mittal B. Association of lipoprotein receptor, receptor-associated protein, and metabolizing enzyme gene polymorphisms with gallstone disease: a case-control study.  Hepatol Res. 2006;  36 61-69
  CrossrefPubMedSearch in Google Scholar
• 96 Mella J G, Schirin-Sokhan R, Rigotti A et al.. Apolipoprotein E polymorphisms and cholesterol gallstone disease in two high-risk populations: genetic evidence that ApoE4 is not a relevant lithogenic risk factor. 2006 (submitted)
  Search in Google Scholar
• 97 Lyons M A, Wittenburg H. Cholesterol gallstone susceptibility loci: a mouse map, candidate gene evaluation, and guide to human LITH genes.  Gastroenterology. 2006;  131 1943-1970
  CrossrefPubMedSearch in Google Scholar
• 98 Nadeau J H, Taylor B A. Lengths of chromosomal segments conserved since divergence of man and mouse.  Proc Natl Acad Sci USA. 1984;  81 814-818
  CrossrefPubMedSearch in Google Scholar
• 99 Sugiyama F, Churchill G A, Higgins D C et al.. Concordance of murine quantitative trait loci for salt-induced hypertension with rat and human loci.  Genomics. 2001;  71 70-77
  CrossrefPubMedSearch in Google Scholar
• 100 DiPetrillo K, Wang X, Stylianou I M, Paigen B. Bioinformatics toolbox for narrowing rodent quantitative trait loci.  Trends Genet. 2005;  21 683-692
  CrossrefPubMedSearch in Google Scholar
• 101 Wang X, Ishimori N, Korstanje R, Rollins J, Paigen B. Identifying novel genes for atherosclerosis through mouse-human comparative genetics.  Am J Hum Genet. 2005;  77 1-15
  CrossrefPubMedSearch in Google Scholar
• 102 Hillebrandt S, Wasmuth H E, Weiskirchen R et al.. Complement factor 5 is a quantitative trait gene that modifies liver fibrogenesis in mice and humans.  Nat Genet. 2005;  37 835-843
  CrossrefPubMedSearch in Google Scholar
• 103 Wang X, Ria M, Kelmenson P M et al.. Positional identification of TNFSF4, encoding OX40 ligand, as a gene that influences atherosclerosis susceptibility.  Nat Genet. 2005;  37 365-372
  PubMedSearch in Google Scholar
• 104 Schafmayer C, Franke A, Egberts J et al.. Investigation of the Lith6 candidate genes ABOBEC1 and PPARG in human symptomatic gallstone disease. 2006 (submitted)
  Search in Google Scholar
• 105 Paumgartner G, Pauletzki J, Sackmann M. Ursodeoxycholic acid treatment of cholesterol gallstone disease.  Scand J Gastroenterol Suppl. 1994;  204 27-31
  PubMedSearch in Google Scholar
• 106 Hou L, Xu J, Gao Y T et al.. CYP17 MspA1 polymorphism and risk of biliary tract cancers and gallstones: a population-based study in Shanghai, China.  Int J Cancer. 2006;  118 2847-2853
  CrossrefPubMedSearch in Google Scholar
• 107 Coelho J C, Vizzoto A O, Salvalaggio P R, Tolazzi A R. Laparoscopic cholecystectomy to treat patients with asymptomatic gallstones.  Dig Surg. 2000;  17 344-347
  CrossrefPubMedSearch in Google Scholar
• 108 Paumgartner G, Sauter G H. Extracorporeal shock wave lithotripsy of gallstones: 20th anniversary of the first treatment.  Eur J Gastroenterol Hepatol. 2005;  17 525-527
  CrossrefPubMedSearch in Google Scholar
• 109 Shiffman M L, Kaplan G D, Brinkman-Kaplan V, Vickers F F. Prophylaxis against gallstone formation with ursodeoxycholic acid in patients participating in a very-low-calorie diet program.  Ann Intern Med. 1995;  122 899-905
  PubMedSearch in Google Scholar
• 110 Moschetta A, Bookout A L, Mangelsdorf D J. Prevention of cholesterol gallstone disease by FXR agonists in a mouse model.  Nat Med. 2004;  10 1352-1358
  CrossrefPubMedSearch in Google Scholar
• 111 Van Der Veere C N, Schoemaker B, Bakker C et al.. Influence of dietary calcium phosphate on the disposition of bilirubin in rats with unconjugated hyperbilirubinemia.  Hepatology. 1996;  24 620-626
  CrossrefPubMedSearch in Google Scholar
• 112 Hafkamp A M, Havinga R, Sinaasappel M, Verkade H J. Effective oral treatment of unconjugated hyperbilirubinemia in Gunn rats.  Hepatology. 2005;  41 526-534
  CrossrefPubMedSearch in Google Scholar
• 113 Mendez-Sanchez N, Roldan-Valadez E, Flores M A, Cardenas-Vazquez R, Uribe M. Zinc salts precipitate unconjugated bilirubin in vitro and inhibit enterohepatic cycling of bilirubin in hamsters.  Eur J Clin Invest. 2001;  31 773-780
  CrossrefPubMedSearch in Google Scholar
• 114 Vitek L, Muchova L, Zelenka J, Zadinova M, Malina J. The effect of zinc salts on serum bilirubin levels in hyperbilirubinemic rats.  J Pediatr Gastroenterol Nutr. 2005;  40 135-140
  PubMedSearch in Google Scholar
• 115 Hofmann A F, Zakko S F, Lira M et al.. Novel biotransformation and physiological properties of norursodeoxycholic acid in humans.  Hepatology. 2005;  42 1391-1398
  CrossrefPubMedSearch in Google Scholar
• 116 Witt H. Chronic pancreatitis and cystic fibrosis.  Gut. 2003;  52 ii31-ii41
  PubMedSearch in Google Scholar
• 117 Harada L M, Amigo L, Cazita P M et al.. CETP expression enhances liver HDL-cholesteryl ester uptake but does not alter VLDL and biliary lipid secretion.  Atherosclerosis. 2006;  , June 24 (Epub ahead of print)
  PubMedSearch in Google Scholar
• 118 Willnow T E, Armstrong S A, Hammer R E, Herz J. Functional expression of low density lipoprotein receptor-related protein is controlled by receptor-associated protein in vivo.  Proc Natl Acad Sci USA. 1995;  92 4537-4541
  CrossrefPubMedSearch in Google Scholar

Henning WittenburgM.D. 

Department of Internal Medicine II, University of Leipzig

Philipp-Rosenthal-Str. 27, 04103 Leipzig, Germany

REFERENCES

• 1 Portincasa P, Moschetta A, Palasciano G. Cholesterol gallstone disease.  Lancet. 2006;  368 230-239
  CrossrefPubMedSearch in Google Scholar
• 2 Cahalane M J, Neubrand M W, Carey M C. Physical-chemical pathogenesis of pigment gallstones.  Semin Liver Dis. 1988;  8 317-328
  Thieme ConnectPubMedSearch in Google Scholar
• 3 Robins S J, Fasulo J M, Patton G M. Lipids of pigment gallstones.  Biochim Biophys Acta. 1982;  712 21-25
  PubMedSearch in Google Scholar
• 4 Wosiewitz U, Schenk J, Sabinski F, Schmack B. Investigations on common bile duct stones.  Digestion. 1983;  26 43-52
  PubMedSearch in Google Scholar
• 5 Friedman G D. Natural history of asymptomatic and symptomatic gallstones.  Am J Surg. 1993;  165 399-404
  CrossrefPubMedSearch in Google Scholar
• 6 Sandler R S, Everhart J E, Donowitz M et al.. The burden of selected digestive diseases in the United States.  Gastroenterology. 2002;  122 1500-1511
  CrossrefPubMedSearch in Google Scholar
• 7 Kratzer W, Mason R A, Kachele V. Prevalence of gallstones in sonographic surveys worldwide.  J Clin Ultrasound. 1999;  27 1-7
  CrossrefPubMedSearch in Google Scholar
• 8 Lammert F, Sauerbruch T. Mechanisms of disease: the genetic epidemiology of gallbladder stones.  Nat Clin Pract Gastroenterol Hepatol. 2005;  2 423-433
  PubMedSearch in Google Scholar
• 9 Paigen B, Carey M C. Gallstones. In: King RA, Rotter JF, Motulsky AG The Genetic Basis of Common Diseases. 2nd ed. New York; Oxford University Press 2002: 298-335
  Search in Google Scholar
• 10 Sampliner R E, Bennett P H, Comess L J, Rose F A, Burch T A. Gallbladder disease in Pima Indians: demonstration of high prevalence and early onset by cholecystography.  N Engl J Med. 1970;  283 1358-1364
  PubMedSearch in Google Scholar
• 11 Everhart J E, Yeh F, Lee E T et al.. Prevalence of gallbladder disease in American Indian populations: findings from the Strong Heart Study.  Hepatology. 2002;  35 1507-1512
  CrossrefPubMedSearch in Google Scholar
• 12 Everhart J E, Khare M, Hill M, Maurer K R. Prevalence and ethnic differences in gallbladder disease in the United States.  Gastroenterology. 1999;  117 632-639
  CrossrefPubMedSearch in Google Scholar
• 13 Mendez-Sanchez N, King-Martinez A C, Ramos M H, Pichardo-Bahena R, Uribe M. The Amerindian's genes in the Mexican population are associated with development of gallstone disease.  Am J Gastroenterol. 2004;  99 2166-2170
  CrossrefPubMedSearch in Google Scholar
• 14 Miquel J F, Covarrubias C, Villaroel L et al.. Genetic epidemiology of cholesterol cholelithiasis among Chilean Hispanics, Amerindians, and Maoris.  Gastroenterology. 1998;  115 937-946
  CrossrefPubMedSearch in Google Scholar
• 15 Carey M C, Paigen B. Epidemiology of the American Indians' burden and its likely genetic origins.  Hepatology. 2002;  36 781-791
  PubMedSearch in Google Scholar
• 16 Neel J V. Diabetes mellitus: a “thrifty” genotype rendered detrimental by “progress”?.  Am J Hum Genet. 1962;  14 353-362
  PubMedSearch in Google Scholar
• 17 Attili A F, Capocaccia R, Carulli N et al.. Factors associated with gallstone disease in the MICOL experience. Multicenter Italian Study on Epidemiology of Cholelithiasis.  Hepatology. 1997;  26 809-818
  CrossrefPubMedSearch in Google Scholar
• 18 Tsai C J, Leitzmann M F, Willett W C, Giovannucci E L. Glycemic load, glycemic index, and carbohydrate intake in relation to risk of cholecystectomy in women.  Gastroenterology. 2005;  129 105-112
  CrossrefPubMedSearch in Google Scholar
• 19 Lowenfels A B. Gallstones and glaciers: the stone that came in from the cold.  Lancet. 1988;  1 1385-1386
  PubMedSearch in Google Scholar
• 20 Barbara L, Sama C, Morselli Labate A M et al.. A population study on the prevalence of gallstone disease: the Sirmione Study.  Hepatology. 1987;  7 913-917
  CrossrefPubMedSearch in Google Scholar
• 21 Nakeeb A, Comuzzie A G, Martin L et al.. Gallstones: genetics versus environment.  Ann Surg. 2002;  235 842-849
  CrossrefPubMedSearch in Google Scholar
• 22 Katsika D, Grjibovski A, Einarsson C et al.. Genetic and environmental influences on symptomatic gallstone disease: a Swedish study of 43,141 twin pairs.  Hepatology. 2005;  41 1138-1143
  CrossrefPubMedSearch in Google Scholar
• 23 Duggirala R, Mitchell B D, Blangero J, Stern M P. Genetic determinants of variation in gallbladder disease in the Mexican-American population.  Genet Epidemiol. 1999;  16 191-204
  CrossrefPubMedSearch in Google Scholar
• 24 Kullak-Ublick G A, Stieger B, Meier P J. Enterohepatic bile salt transporters in normal physiology and liver disease.  Gastroenterology. 2004;  126 322-342
  CrossrefPubMedSearch in Google Scholar
• 25 Hofmann A F. Bile acid secretion, bile flow and biliary lipid secretion in humans.  Hepatology. 1990;  12 17S-22S discussion 22S-25S
  PubMedSearch in Google Scholar
• 26 Baiocchi L, LeSage G, Glaser S, Alpini G. Regulation of cholangiocyte bile secretion.  J Hepatol. 1999;  31 179-191
  CrossrefPubMedSearch in Google Scholar
• 27 Wang P, Kim R B, Chowdhury J R, Wolkoff A W. The human organic anion transport protein SLC21A6 is not sufficient for bilirubin transport.  J Biol Chem. 2003;  278 20695-20699
  CrossrefPubMedSearch in Google Scholar
• 28 Bosma P J, Seppen J, Goldhoorn B et al.. Bilirubin UDP-glucuronosyltransferase 1 is the only relevant bilirubin glucuronidating isoform in man.  J Biol Chem. 1994;  269 17960-17964
  PubMedSearch in Google Scholar
• 29 Nies A T, Keppler D. The apical conjugate efflux pump ABCC2 (MRP2).  Pflugers Arch. 2006;  , July 18 (Epub ahead of print)
  PubMedSearch in Google Scholar
• 30 Robins S J, Fasulo J M. High density lipoproteins, but not other lipoproteins, provide a vehicle for sterol transport to bile.  J Clin Invest. 1997;  99 380-384
  PubMedSearch in Google Scholar
• 31 Cooper A D. Hepatic uptake of chylomicron remnants.  J Lipid Res. 1997;  38 2173-2192
  PubMedSearch in Google Scholar
• 32 Hillebrant C G, Nyberg B, Einarsson K, Eriksson M. The effect of plasma low density lipoprotein apheresis on the hepatic secretion of biliary lipids in humans.  Gut. 1997;  41 700-704
  PubMedSearch in Google Scholar
• 33 Caroli-Bosc F X, Le Gall P, Pugliese P et al.. Role of fibrates and HMG-CoA reductase inhibitors in gallstone formation: epidemiological study in an unselected population.  Dig Dis Sci. 2001;  46 540-544
  CrossrefPubMedSearch in Google Scholar
• 34 Tall A R, Wang N, Mucksavage P. Is it time to modify the reverse cholesterol transport model?.  J Clin Invest. 2001;  108 1273-1275
  CrossrefPubMedSearch in Google Scholar
• 35 Ji Y, Wang N, Ramakrishnan R et al.. Hepatic scavenger receptor BI promotes rapid clearance of high density lipoprotein free cholesterol and its transport into bile.  J Biol Chem. 1999;  274 33398-33402
  CrossrefPubMedSearch in Google Scholar
• 36 Lammert F, Wang D Q. New insights into the genetic regulation of intestinal cholesterol absorption.  Gastroenterology. 2005;  129 718-734
  CrossrefPubMedSearch in Google Scholar
• 37 Yu L, Hammer R E, Li-Hawkins J et al.. Disruption of Abcg5 and Abcg8 in mice reveals the crucial role in biliary cholesterol secretion.  Proc Natl Acad Sci USA. 2002;  99 16237-16242
  CrossrefPubMedSearch in Google Scholar
• 38 Wang R, Salem M, Yousef I M et al.. Targeted inactivation of sister of P-glycoprotein gene (spgp) in mice results in nonprogressive but persistent intrahepatic cholestasis.  Proc Natl Acad Sci USA. 2001;  98 2011-2016
  CrossrefPubMedSearch in Google Scholar
• 39 Smit J J, Schinkel A H, Oude Elferink R P et al.. Homozygous disruption of the murine mdr2 gene P-glycoprotein gene leads to a complete absence of phospholipid from bile and to liver disease.  Cell. 1993;  75 451-462
  CrossrefPubMedSearch in Google Scholar
• 40 Kalaany N Y, Mangelsdorf D J. LXRS and FXR: the yin and yang of cholesterol and fat metabolism.  Annu Rev Physiol. 2006;  68 159-191
  CrossrefPubMedSearch in Google Scholar
• 41 Admirand W H, Small D M. The physicochemical basis of cholesterol gallstone formation in man.  J Clin Invest. 1968;  47 1043-1052
  CrossrefPubMedSearch in Google Scholar
• 42 Carey M C. Critical tables for calculating the cholesterol saturation of native bile.  J Lipid Res. 1978;  19 945-955
  PubMedSearch in Google Scholar
• 43 Portincasa P, Di Ciaula A, vanBerge-Henegouwen G P. Smooth muscle function and dysfunction in gallbladder disease.  Curr Gastroenterol Rep. 2004;  6 151-162
  PubMedSearch in Google Scholar
• 44 Wang D Q, Schmitz F, Kopin A S, Carey M C. Targeted disruption of the murine cholecystokinin-1 receptor promotes intestinal cholesterol absorption and susceptibility to cholesterol cholelithiasis.  J Clin Invest. 2004;  114 521-528
  CrossrefPubMedSearch in Google Scholar
• 45 Marks J W, Bonorris G G, Albers G, Schoenfield L J. The sequence of biliary events preceding the formation of gallstones in humans.  Gastroenterology. 1992;  103 566-570
  PubMedSearch in Google Scholar
• 46 Wilhelmi M, Jungst C, Mock M et al.. Effect of gallbladder mucin on the crystallization of cholesterol in bile.  Eur J Gastroenterol Hepatol. 2004;  16 1301-1307
  CrossrefPubMedSearch in Google Scholar
• 47 Vandenhaute B, Buisine M P, Debailleul V et al.. Mucin gene expression in biliary epithelial cells.  J Hepatol. 1997;  27 1057-1066
  PubMedSearch in Google Scholar
• 48 Lammert F, Carey M C, Paigen B. Chromosomal organization of candidate genes involved in cholesterol gallstone formation: a murine gallstone map.  Gastroenterology. 2001;  120 221-238
  CrossrefPubMedSearch in Google Scholar
• 49 Maurer K J, Ihrig M M, Rogers A B et al.. Identification of cholelithogenic enterohepatic helicobacter species and their role in murine cholesterol gallstone formation.  Gastroenterology. 2005;  128 1023-1033
  CrossrefPubMedSearch in Google Scholar
• 50 Lyons M A, Wittenburg H. Susceptibility to cholesterol gallstone formation: evidence that LITH genes also encode immune-related factors.  Biochim Biophys Acta. 2006;  1761 1133-1147
  PubMedSearch in Google Scholar
• 51 Trotman B W, Bernstein S E, Balistreri W F, Wirt G D, Martin R A. Hemolysis-induced gallstones in mice: increased unconjugated bilirubin in hepatic bile predisposes to gallstone formation.  Gastroenterology. 1981;  81 232-236
  PubMedSearch in Google Scholar
• 52 Soloway R D, Trotman B W, Maddrey W C, Nakayama F. Pigment gallstone composition in patients with hemolysis or infection/stasis.  Dig Dis Sci. 1986;  31 454-460
  CrossrefPubMedSearch in Google Scholar
• 53 Vitek L, Carey M C. Enterohepatic cycling of bilirubin as a cause of “black” pigment gallstones in adult life.  Eur J Clin Invest. 2003;  33 799-810
  CrossrefPubMedSearch in Google Scholar
• 54 Broderick A L, Wittenburg H, Lyons M A et al.. Cystic fibrosis transmembrane conductance regulator gene mutations cause “black” pigment gallstone formation: new insights from mouse models and implications for therapeutic interventions in cystic fibrosis. In: Adler G, Blum HE, Fuchs M, Stange EF Gallstones: Pathogenesis and Treatment. Dordrecht/Boston/London; Kluwer Academics Publishers 2004: 24-27
  Search in Google Scholar
• 55 Angelico M, Gandin C, Canuzzi P et al.. Gallstones in cystic fibrosis: a critical reappraisal.  Hepatology. 1991;  14 768-775
  CrossrefPubMedSearch in Google Scholar
• 56 Fevery J, Blanckaert N, Heirwegh K P, Preaux A M, Berthelot P. Unconjugated bilirubin and an increased proportion of bilirubin monoconjugates in the bile of patients with Gilbert's syndrome and Crigler-Najjar disease.  J Clin Invest. 1977;  60 970-979
  PubMedSearch in Google Scholar
• 57 Wasmuth H E, Keppeler H, Herrmann U et al.. Coinheritance of Gilbert syndrome-associated UGT1A1 mutation increases gallstone risk in cystic fibrosis.  Hepatology. 2006;  43 738-741
  CrossrefPubMedSearch in Google Scholar
• 58 del Giudice E M, Perrotta S, Nobili B et al.. Coinheritance of Gilbert syndrome increases the risk for developing gallstones in patients with hereditary spherocytosis.  Blood. 1999;  94 2259-2262
  PubMedSearch in Google Scholar
• 59 Chaar V, Keclard L, Diara J P et al.. Association of UGT1A1 polymorphism with prevalence and age at onset of cholelithiasis in sickle cell anemia.  Haematologica. 2005;  90 188-199
  PubMedSearch in Google Scholar
• 60 Premawardhena A, Fisher C A, Fathiu F et al.. Genetic determinants of jaundice and gallstones in haemoglobin E beta thalassaemia.  Lancet. 2001;  357 1945-1946
  CrossrefPubMedSearch in Google Scholar
• 61 Conte D, Fraquelli M, Fornari F et al.. Close relation between cirrhosis and gallstones: cross-sectional and longitudinal survey.  Arch Intern Med. 1999;  159 49-52
  CrossrefPubMedSearch in Google Scholar
• 62 Conte D, Barisani D, Mandelli C et al.. Prevalence of cholelithiasis in alcoholic and genetic haemochromatotic cirrhosis.  Alcohol Alcohol. 1993;  28 581-584
  PubMedSearch in Google Scholar
• 63 Zoller H, Cox T M. Hemochromatosis: genetic testing and clinical practice.  Clin Gastroenterol Hepatol. 2005;  3 945-958
  CrossrefPubMedSearch in Google Scholar
• 64 Walshe J M. Hepatic Wilson's disease: initial treatment and long-term management.  Curr Treat Options Gastroenterol. 2005;  8 467-472
  PubMedSearch in Google Scholar
• 65 Oude Elferink R P, Paulusma C C, Groen A K. Hepatocanalicular transport defects: pathophysiologic mechanisms of rare diseases.  Gastroenterology. 2006;  130 908-925
  CrossrefPubMedSearch in Google Scholar
• 66 Jacquemin E, De Vree J M, Cresteil D et al.. The wide spectrum of multidrug resistance 3 deficiency: from neonatal cholestasis to cirrhosis of adulthood.  Gastroenterology. 2001;  120 1448-1458
  CrossrefPubMedSearch in Google Scholar
• 67 van Mil S W, van der Woerd W L, van der Brugge G et al.. Benign recurrent intrahepatic cholestasis type 2 is caused by mutations in ABCB11.  Gastroenterology. 2004;  127 379-384
  CrossrefPubMedSearch in Google Scholar
• 68 Rosmorduc O, Hermelin B, Boelle P-Y et al.. ABCB4 gene mutation-associated cholelithiasis in adults.  Gastroenterology. 2003;  125 452-459
  CrossrefPubMedSearch in Google Scholar
• 69 Rosmorduc O, Hermelin B, Poupon R. MDR3 gene defect in adults with symptomatic intrahepatic and gallbladder cholesterol cholelithiasis.  Gastroenterology. 2001;  120 1459-1467
  CrossrefPubMedSearch in Google Scholar
• 70 Lammert F, Wang D Q, Hillebrandt S et al.. Spontaneous cholecysto- and hepatolithiasis in Mdr2 - / - mice: a model for low phospholipid-associated cholelithiasis.  Hepatology. 2004;  39 117-128
  CrossrefPubMedSearch in Google Scholar
• 71 Pullinger C R, Eng C, Salen G et al.. Human cholesterol 7alpha-hydroxylase (CYP7A1) deficiency has a hypercholesterolemic phenotype.  J Clin Invest. 2002;  110 109-117
  CrossrefPubMedSearch in Google Scholar
• 72 Pullinger C R, Eng C, Malloy M J, Kane J P. Cholesterol 7alpha-hydroxylase (CYP7A1) gene mutation: another cause for gallstone formation?. In: Adler G, Blum HE, Fuchs M, Stange EF Gallstones: Pathogenesis and Treatment. Dordrecht/Boston/London; Kluwer Academics Publishers 2004: 14-23
  Search in Google Scholar
• 73 Miyake J H, Duong-Polk X T, Taylor J M et al.. Transgenic expression of cholesterol-7-alpha-hydroxylase prevents atherosclerosis in C57BL/6J mice.  Arterioscler Thromb Vasc Biol. 2002;  22 121-126
  CrossrefPubMedSearch in Google Scholar
• 74 Lancellotti S, Zaffanello M, Di Leo E et al.. Pediatric gallstone disease in familial hypobetalipoproteinemia.  J Hepatol. 2005;  43 188-191
  CrossrefPubMedSearch in Google Scholar
• 75 Miller L J, Holicky E L, Ulrich C D, Wieben E D. Abnormal processing of the human cholecystokinin receptor gene in association with gallstones and obesity.  Gastroenterology. 1995;  109 1375-1380
  CrossrefPubMedSearch in Google Scholar
• 76 Schneider H, Sanger P, Hanisch E. In vitro effects of cholecystokinin fragments on human gallbladders: evidence for an altered CCK-receptor structure in a subgroup of patients with gallstones.  J Hepatol. 1997;  26 1063-1068
  CrossrefPubMedSearch in Google Scholar
• 77 Miyasaka K, Takata Y, Funakoshi A. Association of cholecystokinin A receptor gene polymorphism with cholelithiasis and the molecular mechanisms of this polymorphism.  J Gastroenterol. 2002;  37 102-106
  PubMedSearch in Google Scholar
• 78 Krejs G J, Orci L, Conlon J M et al.. Somatostatinoma syndrome: biochemical, morphologic and clinical features.  N Engl J Med. 1979;  301 285-292
  PubMedSearch in Google Scholar
• 79 Moschetta A, Stolk M F, Rehfeld J F et al.. Severe impairment of postprandial cholecystokinin release and gall-bladder emptying and high risk of gallstone formation in acromegalic patients during Sandostatin LAR.  Aliment Pharmacol Ther. 2001;  15 181-185
  CrossrefPubMedSearch in Google Scholar
• 80 Puppala S, Dodd G D, Fowler S et al.. A genomewide search finds major susceptibility loci for gallbladder disease on chromosome 1 in Mexican Americans.  Am J Hum Genet. 2006;  78 377-392
  CrossrefPubMedSearch in Google Scholar
• 81 Cohen J C, Kiss R S, Pertsemlidis A et al.. Multiple rare alleles contribute to low plasma levels of HDL cholesterol.  Science. 2004;  305 869-872
  CrossrefPubMedSearch in Google Scholar
• 82 Jiang Z Y, Han T Q, Suo G J et al.. Polymorphisms at cholesterol 7alpha-hydroxylase, apolipoproteins B and E and low density lipoprotein receptor genes in patients with gallbladder stone disease.  World J Gastroenterol. 2004;  10 1508-1512
  CrossrefPubMedSearch in Google Scholar
• 83 Han T, Jiang Z, Suo G, Zhang S. Apolipoprotein B-100 gene Xba I polymorphism and cholesterol gallstone disease.  Clin Genet. 2000;  57 304-308
  PubMedSearch in Google Scholar
• 84 Juvonen T, Savolainen M J, Kervinen K et al.. Polymorphism at the apoB, apoA-I, and the cholesterol ester transfer protein gene loci in patients with gallbladder disease.  J Lipid Res. 1995;  36 804-812
  PubMedSearch in Google Scholar
• 85 Singh M K, Pandey U B, Ghoshal U C et al.. Apolipoprotein B-100 XbaI gene polymorphism in gallbladder cancer.  Hum Genet. 2004;  114 280-283
  PubMedSearch in Google Scholar
• 86 Schafmayer C, Tepel J, Franke A et al.. Investigation of the Lith1 candidate genes ABCB11 and LXRA in human gallstone disease.  Hepatology. 2006;  44 650-657
  CrossrefPubMedSearch in Google Scholar
• 87 Weintraub M S, Eisenberg S, Breslow J L. Dietary fat clearance in normal subjects is regulated by genetic variation in apolipoprotein E.  J Clin Invest. 1987;  80 1571-1577
  PubMedSearch in Google Scholar
• 88 Juvonen T, Kervinen K, Kairaluoma M I, Lajunen L H, Kesaniemi Y A. Gallstone cholesterol content is related to apolipoprotein E polymorphism.  Gastroenterology. 1993;  104 1806-1813
  PubMedSearch in Google Scholar
• 89 Bertomeu A, Ros E, Zambon D et al.. Apolipoprotein E polymorphism and gallstones.  Gastroenterology. 1996;  111 1603-1610
  PubMedSearch in Google Scholar
• 90 Venneman N G, vanBerge-Henegouwen G P, Portincasa P et al.. Absence of apolipoprotein E4 genotype, good gallbladder motility and presence of solitary stones delay rather than prevent gallstone recurrence after extracorporeal shock wave lithotripsy.  J Hepatol. 2001;  35 10-16
  PubMedSearch in Google Scholar
• 91 van Erpecum K J, Portincasa P, Dohlu M H, van Berge-Henegouwen G P, Jungst D. Biliary pronucleating proteins and apolipoprotein E in cholesterol and pigment stone patients.  J Hepatol. 2003;  39 7-11
  CrossrefPubMedSearch in Google Scholar
• 92 Niemi M, Kervinen K, Rantala A et al.. The role of apolipoprotein E and glucose intolerance in gallstone disease in middle aged subjects.  Gut. 1999;  44 557-562
  PubMedSearch in Google Scholar
• 93 Hasegawa K, Terada S, Kubota K et al.. Effect of apolipoprotein E polymorphism on bile lipid composition and the formation of cholesterol gallstone.  Am J Gastroenterol. 2003;  98 1605-1609
  CrossrefPubMedSearch in Google Scholar
• 94 Dixit M, Choudhuri G, Mittal B. Association of APOE-C1 gene cluster polymorphisms with gallstone disease.  Dig Liver Dis. 2006;  38 397-403
  CrossrefPubMedSearch in Google Scholar
• 95 Dixit M, Choudhuri G, Mittal B. Association of lipoprotein receptor, receptor-associated protein, and metabolizing enzyme gene polymorphisms with gallstone disease: a case-control study.  Hepatol Res. 2006;  36 61-69
  CrossrefPubMedSearch in Google Scholar
• 96 Mella J G, Schirin-Sokhan R, Rigotti A et al.. Apolipoprotein E polymorphisms and cholesterol gallstone disease in two high-risk populations: genetic evidence that ApoE4 is not a relevant lithogenic risk factor. 2006 (submitted)
  Search in Google Scholar
• 97 Lyons M A, Wittenburg H. Cholesterol gallstone susceptibility loci: a mouse map, candidate gene evaluation, and guide to human LITH genes.  Gastroenterology. 2006;  131 1943-1970
  CrossrefPubMedSearch in Google Scholar
• 98 Nadeau J H, Taylor B A. Lengths of chromosomal segments conserved since divergence of man and mouse.  Proc Natl Acad Sci USA. 1984;  81 814-818
  CrossrefPubMedSearch in Google Scholar
• 99 Sugiyama F, Churchill G A, Higgins D C et al.. Concordance of murine quantitative trait loci for salt-induced hypertension with rat and human loci.  Genomics. 2001;  71 70-77
  CrossrefPubMedSearch in Google Scholar
• 100 DiPetrillo K, Wang X, Stylianou I M, Paigen B. Bioinformatics toolbox for narrowing rodent quantitative trait loci.  Trends Genet. 2005;  21 683-692
  CrossrefPubMedSearch in Google Scholar
• 101 Wang X, Ishimori N, Korstanje R, Rollins J, Paigen B. Identifying novel genes for atherosclerosis through mouse-human comparative genetics.  Am J Hum Genet. 2005;  77 1-15
  CrossrefPubMedSearch in Google Scholar
• 102 Hillebrandt S, Wasmuth H E, Weiskirchen R et al.. Complement factor 5 is a quantitative trait gene that modifies liver fibrogenesis in mice and humans.  Nat Genet. 2005;  37 835-843
  CrossrefPubMedSearch in Google Scholar
• 103 Wang X, Ria M, Kelmenson P M et al.. Positional identification of TNFSF4, encoding OX40 ligand, as a gene that influences atherosclerosis susceptibility.  Nat Genet. 2005;  37 365-372
  PubMedSearch in Google Scholar
• 104 Schafmayer C, Franke A, Egberts J et al.. Investigation of the Lith6 candidate genes ABOBEC1 and PPARG in human symptomatic gallstone disease. 2006 (submitted)
  Search in Google Scholar
• 105 Paumgartner G, Pauletzki J, Sackmann M. Ursodeoxycholic acid treatment of cholesterol gallstone disease.  Scand J Gastroenterol Suppl. 1994;  204 27-31
  PubMedSearch in Google Scholar
• 106 Hou L, Xu J, Gao Y T et al.. CYP17 MspA1 polymorphism and risk of biliary tract cancers and gallstones: a population-based study in Shanghai, China.  Int J Cancer. 2006;  118 2847-2853
  CrossrefPubMedSearch in Google Scholar
• 107 Coelho J C, Vizzoto A O, Salvalaggio P R, Tolazzi A R. Laparoscopic cholecystectomy to treat patients with asymptomatic gallstones.  Dig Surg. 2000;  17 344-347
  CrossrefPubMedSearch in Google Scholar
• 108 Paumgartner G, Sauter G H. Extracorporeal shock wave lithotripsy of gallstones: 20th anniversary of the first treatment.  Eur J Gastroenterol Hepatol. 2005;  17 525-527
  CrossrefPubMedSearch in Google Scholar
• 109 Shiffman M L, Kaplan G D, Brinkman-Kaplan V, Vickers F F. Prophylaxis against gallstone formation with ursodeoxycholic acid in patients participating in a very-low-calorie diet program.  Ann Intern Med. 1995;  122 899-905
  PubMedSearch in Google Scholar
• 110 Moschetta A, Bookout A L, Mangelsdorf D J. Prevention of cholesterol gallstone disease by FXR agonists in a mouse model.  Nat Med. 2004;  10 1352-1358
  CrossrefPubMedSearch in Google Scholar
• 111 Van Der Veere C N, Schoemaker B, Bakker C et al.. Influence of dietary calcium phosphate on the disposition of bilirubin in rats with unconjugated hyperbilirubinemia.  Hepatology. 1996;  24 620-626
  CrossrefPubMedSearch in Google Scholar
• 112 Hafkamp A M, Havinga R, Sinaasappel M, Verkade H J. Effective oral treatment of unconjugated hyperbilirubinemia in Gunn rats.  Hepatology. 2005;  41 526-534
  CrossrefPubMedSearch in Google Scholar
• 113 Mendez-Sanchez N, Roldan-Valadez E, Flores M A, Cardenas-Vazquez R, Uribe M. Zinc salts precipitate unconjugated bilirubin in vitro and inhibit enterohepatic cycling of bilirubin in hamsters.  Eur J Clin Invest. 2001;  31 773-780
  CrossrefPubMedSearch in Google Scholar
• 114 Vitek L, Muchova L, Zelenka J, Zadinova M, Malina J. The effect of zinc salts on serum bilirubin levels in hyperbilirubinemic rats.  J Pediatr Gastroenterol Nutr. 2005;  40 135-140
  PubMedSearch in Google Scholar
• 115 Hofmann A F, Zakko S F, Lira M et al.. Novel biotransformation and physiological properties of norursodeoxycholic acid in humans.  Hepatology. 2005;  42 1391-1398
  CrossrefPubMedSearch in Google Scholar
• 116 Witt H. Chronic pancreatitis and cystic fibrosis.  Gut. 2003;  52 ii31-ii41
  PubMedSearch in Google Scholar
• 117 Harada L M, Amigo L, Cazita P M et al.. CETP expression enhances liver HDL-cholesteryl ester uptake but does not alter VLDL and biliary lipid secretion.  Atherosclerosis. 2006;  , June 24 (Epub ahead of print)
  PubMedSearch in Google Scholar
• 118 Willnow T E, Armstrong S A, Hammer R E, Herz J. Functional expression of low density lipoprotein receptor-related protein is controlled by receptor-associated protein in vivo.  Proc Natl Acad Sci USA. 1995;  92 4537-4541
  CrossrefPubMedSearch in Google Scholar

Henning WittenburgM.D. 

Department of Internal Medicine II, University of Leipzig

Philipp-Rosenthal-Str. 27, 04103 Leipzig, Germany